The liver is the largest solid organ of the body. It is located on the right side of the abdomen.

The liver is triangular in shape and is divided into a right and left lobe, the right lobe being the larger of the two. It provides several important functions to the body including: Filtering the blood to remove and process toxins. Synthesizing and excreting bile, which is important in processing fat from our diet. Helping regulate blood sugar (glucose) levels. Producing factors that play an important role in blood clotting.

Prognosis is poor, with overall 5-year survival of 5%. If untreated , death occurs in 6-8 weeks

Most common presenting symptom is right upper quadrant abdominal pain, usually dull or aching and may radiate to the right shoulder. Right upper quadrant mass, abdominal distention, fever, malaise, weight loss, and anorexia become evident. Jaundice is present in few patients at diagnosis in primary liver cancer. In cholangiocarcinoma, the presenting symptom is usually obstructive jaundice. If there is portal vein obstruction, ascites and esophageal varices occour.

Serum, bilirubin, alkaline phosphatase, and serum transaminases are all increased. Alpha-fetoprotein: Principal tumor marker for hepatocellular carcinoma elevated in 70% to 95% of patients with the disease. Ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) are used to detect cancer and assess if the tumor can be surgically removed. Arteriography helps determine resectability of liver tumor. Percutaneous needle biopsy or biopsy through ultrasonography may be done. Laparoscopy with liver biopsy may be performed.

1. Choice of treatment depends on Whether tumor is primary or secondary Type and extent of tumor Concomitant diseases Liver functions Patient status

2.Pretreatment therapy

Anemia, clotting deficits, and fluid and electrolyte abnormalities should be corrected Vitamin A, C, D, and B complex can reduce effect of jaundice Pruritus can be relieved with good hygiene and by avoiding products that dry skin and by using oil-based lotions, antihistamines; cholestyramine Nutritional improvement is critical

Cancer that starts in the liver. There are two main types: Hepatocellular carcinoma (HCC) starts in the main cell of the liver (hepatocytes). Cholangiocarcinoma starts in the bile duct. Hepatocellular carcinoma (HCC) is by far the most common type of primary liver cancer. Primary liver tumors usually are associated with chronic liver disease, hepatitis B and C infections, and cirrhosis. Angiosarcoma is a rare liver cancer starting in the blood vessels.

Liver cancer is much common particularly in sub-Saharan Africa and Southeast Asia. Liver cancer is the fifth most common cancer.

Metastases are often from: Lung Kidney Breast Intestinal tract

Infection with Hepatitis B Liver scarring (cirrhosis) due to Hepatitis B or C, inflammation or genetic disorders such as haemochromatosis or alpha 1-antitrypsin deficiency Alcohol drinking over a long period of time Diabetes Smoking High-fat diet Being overweight or obese

Cancer that starts in other part of the body but has spread (metastasized) to the liver. Most common types to spread to the liver start I the digestive sytem: Bowel Pancreas Esophagus Stomach Others that also commonly spread to the liver: Breast Ovary Kidney Lung Secondary cancer is sometimes found at he same time that the primary cancer is diagnosed.

Sometimes he primary cancer cant b found, this is known as Cancer of Unknown Primary (CUP).

The early manifestations of malignancy of the liver include: Pain Continuous dull ache in the right upper quadrant, epigastrium, or back Weight loss Loss of strength Anorexia Anemia The liver may be enlarged and irregular on palpation. Jaundice is present (only if the larger bile ducts are occluded by the pressure of malignant nodules obstruct the portal veins of if tumor tissue is seeded in the peritoneal cavity.)

Metastases from other primary sites are found in the liver in about half of all advanced cancer cases (Bacon & Di Bisceglie, 2000). By way of portal systems or lymphatic channels, or by direct extension from an abdominal tumor, malignant tumors are likely to reach the liver eventually. The liver apparently is an ideal place for these malignant cells to thrive.

The liver cancer diagnosis is based on: Clinical signs and symptoms History Physical examination Results of laboratory X-ray studies Increased serum levels of bilirubin, alkaline phosphatase, AST, GGT, and lactic dehydrogenase may occur. Leukocytosis (increased white blood cells). Erythrocytosis (increased red blood cells).

Hypercalcemia, hypoglycemia, and hypocholesterolemia may also be seen on laboratory assessment. There are two markers that are useful to distinguish between metastatic liver disease and primary liver cancer: The serum level of alpha fetoprotein (AFP), which serves as a tumor marker. Levels of carciembryonic antigen (CEA), a marker of advanced cancer of the digestive tract, maybe elevated.

X-rays Liver scans CT scans Ultrasound studies MRI Arteriography Laparoscopy

Confirmation of a tumors histology can be made by biopsy under imaging guidance (CT scan or ultrasound) or laparoscopically. Local or systemic dissemination of the tumor by needle biopsy or refine-needle biopsy can occur but is rare. Primary HCC diagnosis should be confirmed by frozen section at the time of laparotomy.

Radiation therapy and chemotherapy have been used in treating cancer of the liver with varying degrees of success.

The use of external beam radiation for the treatment of liver tumors has been limited by the radiosensitivity of normal hepatocytes. More effective ways of delivering radiations to tumors of the liver include: Intravenous or intraarterial injections of antibodies tagged with radioactive isotopes that specifically attack tumor-associated antigens. Percutaneous placement of a high-intensity source for interstitial radiation therapy.

Chemotherapy has been used to improve quality of life and pro-long survival. May also be used as a therapy after surgical resection of hepatic tumors. Systemic chemotherapy and regional infusion are used to administer antineoplastic agents. An implantable pump is used to deliver highconcentration chemotherapy to the liver through the hepatic artery.

Percutaneous biliary drainage is used to bypass biliary ducts obstructed by the liver, pancreatic, or bile ducts in patients with inoperable tumors or those who are poor surgical risks. Complications include sepsis, leakage of bile, hemorrhage, and reobstruction of the biliary system. Observe patient for fever and chills, bile drainage around the catheter, changes in vital signs, and evidence of biliary obstruction, including increased pain or pressure, pruritus, and recurrence of jaundice.

Hyperthermia: heat by laser or radiofrequency energy is directed to tumors to cause necrosis of the tumors while sparing normal tissue. Cryosurgery is a newer treatment modality. Embolization of arterial blood flow to the tumor; effective in small tumors; injection of small particulate embolic or chemotherapeutic agents may be used to cause tumor necrosis. Immunotherapy: lymphocytes with antitumor reactivity are administered.

Surgical resection is a treatment of choice when HCC is confined to one lobe of the liver When the primary site can be completely excised & metastasis is limited, hepatic resection can be performed Metastases to the liver are rarely limited or solitary Surgeons have capitalized on the regenerative capacity of the liver cells removing 90% of it The presence of cirrhosis limits the ability of the liver to regenerate Staging of liver tumors aid in predicting the chances of surgical cure Nutritional, fluid and general physical status is assessed in preparation for a surgery Patients aided psychologically in preparing for the surgery

Extensive diagnostic studies may be performed as well as Specific studies that may include:

Liver scans Liver biopsy Cholangiography Selective Hepatic angiography Percutaneous needle biopsy Peritoneoscopy Laparoscopy Ultrasound CT scans MRI Blood tests, Particularly determinations of serum alkaline phosphate, AST, and GGT

Primary tumor (T) TX- Primary tumor To- No evidence of primary tumor T1-Solitary tumor without vascular invasion T2-Solitary tumor without vascular invasion or multiple tumors -none more than 5 cm T3-Multiple tumors more than 5 cm or tumor involving a major branch of the portal or hepatic vein(s) T4-Tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of visceral peritoneum

NX -Regional lymph nodes cannot be assessed N0 -No regional lymph node metastasis N1 -Regional lymph node metastasis

Mx -Distant metastasis cannot be assessed Mo -No distant metastasis M1 -Distant Metastasis

Stage I
Stage II Stage IIIA Stage IIIB Stage IIIC Stage IV

T1
T2 T3 T4 Any T Any T

No
No No No N1 Any N

Mo
Mo Mo Mo Mo M1

Removal of a lobe of the liver is the most common surgical procedure. For right liver lobectomy or an extended right lobectomy a thoracoabdominal incision wll be used. An extensive abdominal incision is made for a left lobectomy.

Cyrosurgery (cyroablation), tumors are destroyed by liquid itrogen at -196C. This technique ha been used alone. Its efficacy is still being evaluated

Procedure involves total removal of the diseased liver and its replacement with a healthy liver in the same anatomic location (orthotopic liver transplantation [OLT]). It is not a routine procedure and it may be accompanied by complications. Recurrence of primary liver malignancy has been reported. The patient with small tumors may have a good prognosis after transplantation. Established therapeutic modality rather than experimental procedure to treat these disorders. To prepare the patient and family for liver transplantation, nurses in all settings must understand the process and procedure of liver transplantation.

The postoperative complication rate is high because of technical complications or infections. Immediate postoperative complications may include: Bleeding common in postoperative period Infection leading cause f death in liver transplantation. Rejection a key concern.

Assess for problems related to cardiopulmonary involvement, vascular complications, and respiratory and liver dysfunction. Give careful attention to metabolic abnormalities (glucose, protein, and lipids).

Provide close monitoring and care for the first 2 or 3 days. Encourage early ambulation, and initiate other postoperative care measures. Closely monitor the patient undergoing cryosurgery for hypothermia, hemorrhage, bile leak, and myoglobinuria. Instruct patient about the importance of followup visits. Encourage patient to resume activities as soon as possible, but caution patient to avoid activities that may damage the pump.

Teach patient about signs of complications, and encourage patient to notify nurse or physician if problems or questions occur. Provide reassurance and instructions to patient and family to reduce fear. Refer patient for home care. Assist patient and family in making decisions about hospice care, and initiate referrals. Encourage patient to discuss end-of-life care.

Therapeutic Interventions Radiation therapy can help reduce pain and discomfort. Liver cancer is radiosensitive, but treatment is restricted by the limited radiation tolerance of normal liver. Hyperthermia has been used to treat hepatic metastases. Management of ascites and edema through fluid restriction, albumin, and diuretics.

Chemotherapy is used as an adjuvant therapy after surgical resection of liver cancer.

Systemic chemotherapy is the only treatment

Hepatic artery occlusion and embolization with chemotherapeutic agents is another possible method. Immunotherapy is currently under investigation.

applicable once the cancer has spread outside the liver. Regional infusion chemotherapy by implantable pump has been used to deliver a high concentration of chemotherapy directly to the liver through the hepatic artery.

Surgery is the best treatment but is only feasible in 25% of cases, after extent of tumor and hepatic reserve have been considered. Surgical resection may be along anatomic divisions of the liver or nonanatomic resections. Freezing hepatic tumors by cryosurgery is a new modalilty that preserves normal liver. Liver transplantation has been performed to treat liver tumors, but results have been poor because of the high rate of recurrent primary liver malignancy. It is now recommended that the patient be treated before and after transplantation with chemotherapy and radiation therapy.

Percutaneous transhepatic biliary drainage (PTBD) is used to drain obstructed biliary ducts in patients with inoperable tumors or in patients considered poor surgical risks. A percutaneous catheter drains the biliary tree to relieve jaundice, decrease pruritus, and decrease anorexia. Percutaneous or endoscopic placement of internal stents may also be used as palliative treatment for a patient with obstructed bile ducts with a terminal diagnosis.

Assess the patients response to pain control measures. Monitor vital signs, intake and output, and daily weights to detect fluid balance. Measure and record abdominal girth daily. Monitor laboratory values for liver function. Note subtle changes in mental status indicating hepatic encephalopathy. Monitor for signs of malnutrition, including weight loss, loss of strength, anemia.

Administer pain control agents as ordered, keeping in mind decreased liver metabolism. Monitor signs of drug toxicity. Provide nonpharmacologic methods of pain relief, such as massage and guided imagery. Position the patient for comfort usually in semi Fowlers position. Encourage the patient to eat small meals and supplementary liquid feedings. Asses and report factors that may increase nutritional needs: Increased body temperature, pain, signs of infection, stress level. Encourage additional calories as tolerated. Restrict sodium and fluid intake as prescribed.

If the patient has PTBD, monitor catheter exit site for bleeding or bile drainage, and asses drainage in bag for color, amount, consistency. The drainage initially may have some blood mixed with bile but should clear within a few hours.
Flush catheter if ordered Check for and report signs of peritonitis from bile leaking

into abdomen: Fever, chills, abdominal pain and tenderness, distention.

Provide psychological support to patient and family to help them cope with uncertain prognosis.

Instruct the patient and family on preparation for surgery, reinforcement and clarify proposed surgical procedure, and review postoperative instructions. Instruct the patient to recognize and report signs and symptoms of complication. Instruct the patient in continued surveillance for recurrence. Instruct the patient and family in care of any tubes or drains.